oral manifestation of diabetes mellitus

بسم الله الرحمن الرحيم : بسم الله الرحمن الرحيم Oral manifestations of diabetes mellitus and it`s effect on oral tissues Abstract Many systemic diseases have oral manifestations. The oral cavity might well be thought of as the window to the body because oral manifestations accompany many systemic diseases. These oral manifestations must be properly recognized if the patient is to receive appropriate diagnosis and referral for treatment. The lesions of the oral mucosa, tongue, gingiva, dentition, periodontium, salivary glands, facial skeleton, extraoral skin and other related structures caused by some of the more common systemic diseases
Diabetes mellitus : Diabetes mellitus It is acommon chronic endocrine disorder that occurs as a result of a deficiency of insulin or resistance to insulin A syndrome of abnormal carbohydrate,fat and protein metabolism Characterized by abnormal high blood glucose levels As insulin important to lower blood glucose level by 1- increaseglucose uptake by body cells 2-glucose oxidation for energy 3-glycogenesis as excess glucose turn to glycogen in liver So defective insulin either by defect in beta pancreatic productive cells or defect in receptors for insulin binding so accumulation of glucose in blood hyperglycemia
Slide 4: 70-110mg/dl completelyfasting for 6 hours before test -----post prandial 110-180mg/dl as 2hours after eat if increases means hyperglycemia and diagnosed as diabetes pt. Normal blood glucose levels- -----on fasting Pre-diabetes Pre-diabetes is a condition that occurs when a person's blood glucose levels are higher than normal but not high enough for a diagnosis of type 2 diabetes. There are 54 million Americans who have pre-diabetes, in addition to the 20.8 million with diabetes. As a fasting blood glucose level between 100 and 125 mg/dl signals pre-diabetes. two-hour blood glucose level is between 140 and 199 mg/dl, the person tested has pre-diabetes.
Slide 5: etiologyand types
Diabetes Insipidus : Diabetes Insipidus {Fault diabetes}1-Diabetes insipidus is an uncommon form of diabetes which results either from a failure of the pituitary gland to secrete enough antidiuretic hormone (ADH) or from a failure of the kidneys to respond to ADH. 2-The main symptoms are excessive thirst and the passing of large quantities of dilute urine. If water is unobtainable or witheld, the affected person becomes dehydrated and will eventually become comatose. 3- The condition is treated by giving analogues of ADH such as lypressin or desmopressin.
Slide 8: Prevalance and incidence of diabetes There are 20.8 million children and adults in the United States, or 7% of the population, who have diabetes. While an estimated 14.6 million have been diagnosed with diabetes, unfortunately, 6.2 million people (or nearly one-third) are unaware that they have the disease. Diabetic peoples have higher risk of mortality and shorter life expectancy than these without Diabetes was the sixth most common cause of death in U.S.A in2001 There are many oral manifestations of diabetes mellitus, some having been described as early as 1862.
Epidemiological study : Epidemiological study The main purpose of this study was to analyze the oral health conditions and some oral manifestations that are present in the diabetic patient type 2, such as bucal hygiene, caries, periodontal disease, and fungal (candidiasis) and post-extraction infections compared with non diabetic patients We found that the 83% of diabetic patients were not under medical supervisión (according with the clinical tests
Risk factors in development of diabetes : Risk factors in development of diabetes 1-obesity 2-high risk of ethnic background-afrecian-american 3-hypertension 4-high denisty lipoproteins 5-history of gestational diabetes 6-impaired glucose tolerance as history of blood glucose110-126mg/dl 7-history of vascular disease
Slide 11: Diagnosis of diabetic patient A-diagnostic lab. tests Diagnosis depends solely on detection of hyperglycemia 1---As detection of blood glucose level Fasting--------------------= more than 126mg/dl Pt.must fasted for 6 hours Post prandial--------------= more than 200mg/dl Normal 70---110mg/dl Prediabetic-------- a fasting blood glucose level between 100 and 125 mg/dl --------- two-hour blood glucose level is between 140 and 199 mg/dl 2--glucose in urin---------by clinistix ;[can done in clinic] rapid screening test 3—monitoring glycosylated hemoglobin normally formed by addition of hexose molecules to beta chain of hemoglobin A measured glycohemoglobin Hba1c most common degree of glycosylation of HbAdirectly depend on conc. Of blood glucose normal---------------------------less than 7% controlled pt. ------------------7=9% uncontrolled--------------- more than 13% B-clinical sign and symptoms
Diagram showing the main features of diabetes mellitus : Diagram showing the main features of diabetes mellitus
Clinical manifestations : Clinical manifestations diabetes is a disease that involves the entire body as affect vascular sys. Causing accelerated atherosclerosis [ thickening of blood vessel wall by fibrofatty plaques ] 1-increasingblood pressure 2-diabetes retinopathy[lead to hemorage and blindness] 3-kidney failure 4-ulcer and gangrenes esp. feet 5-coma by ketoacidosis 6-heart disease microangiopathic changes[retina –kidney] accelerated atherosclerosis lead to 1-impaired blood circulation 2-impaired oxygen transport to tissues 3-impaired nutrition to tissues
Slide 14: nervous system causing variable neurological complaints decrease resistance to infection esp. in uncontrolled diabetes causing neuropathy and paresthesias [any damage in peripheral nerves or nervous sys.]] increases skin infections esp. furuncles [boils] urinary tract infection tuberculosis common candidal infection [ vaginal cadidosis] polyurea------------ polydipsia coma with fruity breath [hyperglycemic coma] grinspan syndrome---------1-diabetic patient 2-hypertension 3-lichenoid reactions due to hypotensive or hypoglycemic druges
oral manifestations of D.M : oral manifestations of D.M 1- generalized stomatitis 2- Compromised periodontal health 3- oral candidosis 4-xerostomia 5-glossodynia of burning mouth syndrom 6- Lichenoid drug reactions (oral hypoglycaemic drugs) 7- diabetic sialadenosis [bilateral asymptomatic parotid gland enlargement] as in some patients fat deposition in gland and hypertrophy of salivary gland tissues 8- acute hyperplastic gingivitis 9-altered tast 10-accentuated response to dental plaque 11- Mucormycosis and benign migratory glossitis [mucormycosis----- rare fungal infection affect palate and maxillary sinus] 12-altered subgingival flora [by immunological or salivary changes] 13-erythematous candidiasis presents as central pappilary atrophy of the dorsal Tongue surface 14-neurosensory dysfunction------burning mouth syndrome 15- dental caries 16-Diabetes may increase risk for oral cancer through the insulin receptor substrate-1 and focal adhesion kinase pathway
Slide 17: Chronic Atrophic Candodosis (Denture Stomatitis) Erythematous Candidosis: Glossitis
Periapical periodontitis median rhemboid glossitis : Periapical periodontitis median rhemboid glossitis
Aggressive stomatitis xerostomia : Aggressive stomatitis xerostomia Xray showing bone loss
Lichenoid drug reaction : Lichenoid drug reaction DIABETES gingivitis
All these oral manifestations throughChanges in oral tissues byD.M : All these oral manifestations throughChanges in oral tissues byD.M Changes in the Oral Cavity Diabetes can lead to changes in the oral cavity. Of particular concern to dentists and dental hygienists are the effects of diabetes on the health of 1- gingiva (gums) and periodontal tissues 2-dental pulp 3-bone 4-oral soft tissues Diabetes can affect the entire body. Whether your diabetes affects your oral health depends on how well you are able to control your blood sugar. If your diabetes is under control, the effects on your oral health should be minimized.
Slide 22: under control, the oral effects can be dramatic People with diabetes can have: Rapidly progressing periodontal (gum) disease Gum inflammation (gingivitis) Dry mouth (xerostomia) Poor healing of oral tissues Oral candidiasis (thrush) Burning mouth and/or tongue However, if your diabetes is not
Effect on teeth : Effect on teeth 1-hard structure 2-dental pulp dental decay caused by a bacterial infection of the hard tissue of the tooth. bacteria and food particles will form plaque on the tooth surfacesproduce acid w` erodes calcium on tooth enamel minute cavities if untreated eat through tooth enamel and begin eroding the dentine layer beneathas decay continues bacteria migrate through dentine layer and infect pulp inside toothtooth acheinfection proceeds asignificant number of bacteria invade pulp then nerve may die and pain may stop bec. Body still fighting infectionabscesspainful tooth esp. on chewing untreated abscessbone around tooth begin erodedsmall fistula formed
Slide 24: risk increases in diabetic pt. esp. if uncontrolled or undiagnosed as salivary gland dysfunction and hyposalivation occur because saliva normally washes away sugars and food particles that are fuel for decay-causing bacteria Recent studies have shown that uncontrolled diabetics have decreased salivary flow diabetics as a group have more or less tooth decay than non-diabetics If have dry mouth, practice regular oral hygiene to prevent decay You may want to talk to your dentist or physician about artificial saliva, or other means of reducing your dry mouth. Fluoride rinses or gels should be used to reduce the possible increase in decay rate
2-Effect on dental pulp : 2-Effect on dental pulp [acc.to journal of oral science september2006 dr Orlandol.Catanzaro] studies of rates e`streptozotocin-induced diabetes reveales marked reduction in plasma blood flow in dental pulp animals e` uncontrolled diabetes show periapical and periodontal lesions objective of study to determine effect of diabetes on pulpal inflammation and chemical mediators uncontrolled or poorly controlled diabetes has more acute inflammatory reaction bec.--------vascular leakage and cell dehiscence long standing diabetes resulting in angiopathy and thickened basement membrane in dental blood vessels ------ marked reduction in plasma blood flow
Slide 27: effects of short and longstanding diabetes on pulp components as nitrites, kallikrein,alkalinephosphatase and collagen 1-increases nitrite and kallikrein in dental pulp tissue higher in diabetic rates only nitrite decreased after 90day of STZ treatment 2-myeloperoxidase activity showes changes after 30—90 day after STZ injection 3-change alkaline phosphatase after30-90day after STZ treatment 4-concentration of collagen decreased because dental pulp has no or limited collateral circulation so conditions induced by diabetes as periodontitis may affect dental pulp via periapical way
Slide 28: results of study reveales 2types of pulp damage acc.to duration of diabetes 1-occur after short period of diabetes----------cause early inflammatory alteration e`increase conc. Of kallikrein and nitrites neutrophiles and macrophages has role in formation of proinflamatory mediators in dental pulp cytokines[IL-1 TNF] , bradykinines ,prostaglandine and leukotrienes inflammatory mediators in early inflammation decreases leukocytes microbicidal activity by increased endothelial cell permeabelity and accumulation of atheromatous deposite in vessels lumen decreases collagen syntheses 2-longer period of diabetes --------- irreversible pupal changes---- pulp necrosis progressive deterioration of pulp matrix component 2 inflammatory component increased kallikrein and myeloperoxidase this reflect inflammatory process and AGEs decreases collagen synsesis
effect on bone : effect on bone [Dr. Juan Carlos Ferrer García 2008 Medicina Oral S.L] through1-hyperglycemia..2-type of diabetes.3-insulin hyperglycaemia . Effect of1- Chronic hyperglycaemia affects different tissue structures, produces an inflammatory effect in vitro, has been shown to be a stimulus for bone resorption Bone loss in diabetes does not seem to depend on an increase in osteoclastogenesis as in the reduction in bone formation Hyperglycaemia inhibits osteoblastic differentiation and alters the response of the parathyroid hormone that regulates the metabolism of phosphorus and calcium it produces a deleterious effect on the bone matrix and its components and also affects adherence, growth and accumulation of extra-cellular matrix Mineral homeostasis, production of osteoid bone formation has been shown to be clearly diminished in various experimental models of diabetes
2. Differences by type of diabetes : 2. Differences by type of diabetes Type 1 diabetes mellitus is an auto-immune disease affecting the beta cells in the pancreas that produce insulin, thus making it necessary to use exogenous insulin to ensure survival and prevent or delay the chronic complications of this illness type 2 diabetes mellitus, on the other hand, is a multi-factorial disease resulting from environmental effects on genetically predisposed individuals and is related with obesity, age and a sedentary lifestyle. In these patients, there is a defect in the secretion of insulin together with a greater or lesser degree of insulinopenia The treatment of type 2 diabetics includes, in stages, measures relating to their diet and lifestyle, oral hypoglycaemic drugs either alone or in combination, and insulin. 4-In both type 1 and type 2 diabetes, the therapeutic goal focuses on maintaining blood-glucose at normal or near-normal levels. Glycosylated haemoglobin (HbAc1) is used to verify the mean glycaemia of a patient
Slide 32: Type 1 diabetes produces a reduction in bone mineral density through mechanisms that have not yet been sufficiently clarify 5-it has been attributed to both a lower formation of bone and also to a greater rate of bone loss 6-This alteration has not been demonstrated in patients with type 2 diabetes and, in some studies, it even seems that there is greater bone mineral density than in the control subjects Experimental models of type 2 diabetes have shown a reduction in both bone formation and bone resorption, which might explain this apparently contradictory effect
3. Effects of insulin on bone : 3. Effects of insulin on bone Insulin directly stimulates the formation of osteoblastic matrix. In experimental models of diabetes, the normoglycaemia levels obtained by treatment with insulin brought about growth in bone matrix and formation of osteoid similar to control subjects While hyperglycaemia may reduce bone recovery by as much as 40% following circular osteotomies, treatment with insulin normalizes this recovery index, this indicating that the deterioration of the bone is strictly related to poor control of diabetes
Slide 36: Resorbing Bone Osteoclast bone marrow changes e`fat cells osteomyelitis acute
Effect of diabetes on osseointegration of dental implant : Effect of diabetes on osseointegration of dental implant the effect of diabetes on implants has revealed an alteration deficient 2-in bone remodelling processes 1-mineralization, leading to less osseointegration Some studies shown, although the amount of bone formed is similar when comparing diabetes-induced animals with controls, there is a reduction in the bone-implant contact in diabetics The reduction in the levels of bone-implant contact confirms that diabetes inhibits osseointegration. This situation may be reversed by treating the hyperglycaemia and maintaining near-normal glucose levels If insulin is used, the ultra-structural characteristics of the bone-implant interface become similar to those in the control group so metabolic control is essential for osseointegration to take place, as constant hyperglycaemia delays the healing of the bone around the implants numerous studies have shown that insulin therapy allows regulation of bone formation around the implants and increases the amount of neoformed bone, it was not possible to equal the bone-implant contact when compared with non-diabetic groups .
Conclusions : Conclusions hyperglycaemia has a negative influence on bone formation and remodelling and reduces osseointegration of implants Soft tissue is also affected by the microvascular complications deriving from hyperglycaemia, vascularization of the tissue is compromised, healing is delayed and wounds are more predisposed to infection. This entails an increase in the percentage of failures in the implant treatment of diabetic patients. Although there is a higher risk of failure in diabetic patients, experimental studies have shown that the optimization of glycaemic control improves the degree of osseointegration in the implants. .
Effect on periodontal tissues : Effect on periodontal tissues < National Diabetes Education Program (NDEP)> Periodontal disease is a bacterially induced, chronic inflammatory disease that destroys the connective tissue and bone supporting the teeth and can lead to tooth loss Patients with diabetes are at greater risk for periodontal disease. Diabetes causes blood vessel thickening, which slows down the flow of blood to body tissues , including the gums and dental bones. Blood flow is crucial in providing important nutrients and eliminating harmful wastes from body tissues. As a result of lowered blood flow, the gum and bone tissue supporting the teeth become less healthy and less resistant to infection from bacteria found in dental plaque. Recent research suggests a two-way connection between diabetes and periodontal disease. Not only are people with diabetes more susceptible to periodontal disease, but the presence of periodontal disease may also make glycemic control more difficult . so Proper care of the mouth that includes treatment of peridontal disease may help people with diabetes achieve better glycemic control.
Slide 42: Uncontrolled diabetes impairs white blood cells called neutrophils, which are a main defense against bacterial infection. Because periodontal disease is a bacterial infection can affect one tooth or many teeth. The main cause of periodontal (gum) disease is bacterial plaque However, there are many factors that influence the health gums the of : begins when the bacteria in plaque?the sticky, colorless film that constantly forms on teeth? cause the gums to become inflamed. gingivitis ,,the mildest form of the disease, the gums redden, swell and bleed easily. usually little or no discomfort. Gingivitis often is caused by inadequate oral hygiene and is reversible with professional treatment and good oral home care. Untreated gingivitis can advance to periodontitis
Slide 45: Most people with diabetes do not experience pain with periodontal disease, many be asymptomatic.
Effect on tongue : Effect on tongue THE HISTOLOGICAL CHANGES OF THE DORSAL SURFACE OF THE TONGUE DUE TO ALLOXAN INDUCED DIABETIC RATS AND THE PROTECTIVE ROLE OF VITAMIN E AGAINST THESE CHANGES The results showed that vitamin E is an essential nutrient which has a biological effect as an antioxidant preventing the auto oxidant effect of diabetes on oral tissues. Vitamin E supplementation leads to re epithelialization and regeneration of collagen, muscles and nerve fibers. Diabetic patients could take vitamin E to overcome the destructive effect of diabetes on oral tissues, especially the dorsal surface of the tongue and taste sensation
Slide 47: Glossitis
Conclusion : Conclusion Finally it is shown that diabetes affect the entire body. Whether your diabetes affects your oral health depends on how well you are able to control your blood sugar. If your diabetes is under control, the effects on your oral health should be minimized. On concern to dentists and dental hygienists the effects of diabetes on the health of the gingiva (gums) and periodontal tissues
Slide 49: Oral signs and symptoms of diabetes includes burning mouth syndrome taste disorders abnormal wound healing fungal infections (candidiasis a fruity (acetone) breath xerostomia (dry mouth or a change in saliva thickness other systemic findings such as excessive loss of fluids through frequent urination  altered response to infection  altered connective tissue metabolism neurosensory dysfunction  microvascular changes medications causing dry mouth and possible increased glucose concentration in saliva
Slide 50: all these manifestations occurred as a result of diabetes effect on 1- white blood cells function 2-phagocytic activity reduced 3-chemotaxis delayed 4-abnormal collagen production 5-decreased blood flow by thickening vessel wall So diabetic patient need excellent oral hygiene measures to prevent or decreases oral complications as Brushing teeth regularly, preferably in the morning and before bed, and floss your teeth at least once a day. Make sure that you use a soft toothbrush and that the bristles reach the gum line when you brush. Have your teeth professionally cleaned every six months to one year to prevent plaque from becoming calculus and to remove any calculus that may this treating gingivitis and stop it`s advancement to periodontitis

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